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Disclosure of Commercial Support This program has received NO financial support This program has received NO in-kind support Potential for conflict(s) of interest: –NONE

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Mitigating Potential Bias N/A

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Objectives This presentation will review: 1.How to screen for youth with alcohol/drug problems 2.How to help youth in the office using motivational interviewing and interpersonal strategies, with a focus on… 3.How empathy, validation and unconditional acceptance is perhaps the most powerful way to reconnect youth to parents and vice- versa

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“So what? Its going to be legal anyways…” Britney is a 15-yo in your primary care practice You have known since she was a young age as a sweet, but always active and spirited child However, as she has gotten older, she has become more moody, strong willed and defiant… You look at your schedule, and see that Britney is booked to see you later today for MARIJUANA PROBLEMS

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Britney’s mother “Why is she doing marijuana? When she was younger, she was cheerful, happy, and a good, well behaved kid.

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Etiology of Substance Use An Attachment Perspective

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Q. Ever notice that it’s the older children like teens that turn to drugs?

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Q. Ever notice that young children seem happier than older children?

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Q. Why are young children so happier?

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A. Because they are closely attached to parents.

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Q. When a young child needs something from you, do they let you know?

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A. Young children are very good about letting you know they need something! (Unlike teens who may just as likely say everything is “fine” and storm off to their room…)

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Q. When a young child cries, what do you do?

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A. When a young child cries, what do you do?  Pick up child and provide physical comfort and reassurance  Food  Diaper change Its not a very long list of things!

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1. Young children express their needs… 2. Caregivers meet the needs (which are a smaller list and easier to meet than with older kids) Young children are well attached to caregivers because: Caregiver Child 3. Attachment forms with caregiver (or whoever meets their need)

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Q. What happens when you consistently meet a child’s needs? A. Secure attachment between child and parent Ainsworth; Bowlby Child’s working model / schema View of world: “The world is a safe place… I can trust others…” View of self: “I feel better thus I am competent…”

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Attachment and Resiliency Resiliency: The ability to overcome adversity Not everyone exposed to stresses develops problems; many in fact, will thrive despite stress Q. What is the single most important resiliency factor?

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Attachment and Resiliency Resiliency: The ability to overcome adversity Not everyone exposed to stresses develops problems; many in fact, will thrive despite stress Q. What is the single most important resiliency factor? –Secure attachments to caregivers and nurturing adults Studies of high school student mental health show that –Parent-child relationships are the key to mental health –Strength of peer relations is not the key Bowlby, 1940; Ainsworth, 1979; Schore, 2001; Neufeld, 2004

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Attachment Theory Why is attachment so important for us?

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Many species have young that can survive on their own…

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Q. What does a human baby/child have to do in order to survive? Child

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Turning to peers is bad because… Peers can never meet a child’s emotional/ attachment needs as well as only healthy parents can Only parents can reliably provide emotional support, validation and unconditional acceptance Peers –Friendships come and go –Peers are still maturing –Your BFF one day can be your worst enemy the next…

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Turning to peers as a primary source of emotional support is like putting all your attachment eggs in one basket Child Parent(s) Peers

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Peers/Friends are okay if… If you truly have mature peers (which usually doesn't happen until adulthood), then peers may indeed provide the stable support that perhaps parents cannot provide…

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Turning to drugs is bad because… Drugs can never meet a child’s emotional/ attachment needs as well as only healthy parents can Only parents can reliably provide emotional support, validation and unconditional acceptance Drugs may help one feel temporarily better, but it is not a long-term solution…

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Why do today's young people turn away from parents as they get older?

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Q. Back in the old days, what did kids learn about parents from these shows?

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VIDEO CLIP: MODERN TELEVISION SHOW

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Q. What is the message about parents?

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Media helps push our kids away... Today’s kids (either your kids or your kids’ peers) spend several hours a day on average in front of a TV, or other screens Media messages are that Parents are lame The secret to happiness and success is having friends, and turning to your peers

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Q. A child is playing ball with a parent. Who is going to be more competent at it?

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A. The parent and thus the child learns that parents are competent and to look up to parents… In traditional societies, the young learn from and thus respect their elders… (But not so in modern ones!) Margaret Mead, 1956

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VIDEO CLIP: MODERN TELEVISION SHOW

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Q. In today’s technology obsessed world, who is better with modern technology, our 1) children or 2) parents?

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A. Our children know more about the technology than we do, which makes them think they are superior… Boy, my dad is terrible! Boy, I hate these video games!

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Economic Factors: Housing costs 2-3X more than in the 1970s – 40% of Canadian couples divorce… thus both parents work outside the home.. Q. So who are the kids hanging out with when both parents are working outside the home? Kershaw, 2012

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From an early age, our children spend more time with peers in daycare and school than they do with adults.

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How modern technology weakens relationships, even the peer-peer relationships

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Violence negatively affects children’s brains Violent video games are harmful – Research confirms numerous harmful effects of video games on behaviour, mood, relationships, physical health, sleep Violence in media in general – Children/youth are exposed to violence in movies, televisions, popular culture – All of this desensitizes us to violence and cruelty American Academy of Paediatrics, Media Policy Statement

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American Medical Association's Guidelines for Adolescent Preventive Services recommends: –Adolescents be asked annually about their use of alcohol –Those who report any use during the past year should be assessed further

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Screening with CRAAFT In the past year, have you: –Drank any alcohol? –Smoked any marijuana or hashish? –Used anything to get “high”? If YES to any of the above, then ask the patient the CRAAFT…

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Screening with CRAFFT C)arEver ridden in a CAR driven by someone (which includes yourself) who had been using alcohol or drugs at the time? R)elaxEver use alcohol or drugs to RELAX? A)loneEver use alcohol / drugs while you are ALONE? F)orgetEver FORGET things you did while on alcohol or drugs? F)riends/Fa mily Do your FAMILY/FRIENDS ever tell you that you should cut down on alcohol or drugs? T)roublesEver gotten into TROUBLE while using alcohol or drugs?

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Q. What was this alliance based on? Stalin (Russia) Truman (USA)Churchill (UK)

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Therapeutic Alliance We all know its important, but exactly what is it? Q. What is the most important component of the therapeutic alliance? A. It depends…

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83 Conclusion? Trust isn’t everything Sometimes more important is… –Agreement on (common) goals –Agreement on tasks Situations where there is not (yet) a good bond include: –You’ve just met the patient / client –Your patient values their Autonomy / Independence over wanting to please you (i.e. most teenagers!)

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What if my patient gives me an unhealthy goal? Underneath every unhealthy goal is ultimately a healthy one… Patient: So what if I cut? Healthy goal: To feel better Patient: I’ve had thoughts of killing myself, I can’t take it anymore. Clinician: What makes you want to kill yourself? Patient: I’m depressed all the time, and I just want to stop feeling like this. And my parents just fight all the time. Clinician: What if we could find a way to help your mood? And perhaps help your parents not fight all the time?

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What if my patient gives me an unhealthy goal? Self-cutting Self-cutting –Patient: So what if I cut? Lots of kids cut. Q. What do you say? –A. Clinician: I agree, you should keep cutting. –B. Clinician: What makes you want to cut?

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What if my patient gives me an unhealthy goal? Self-cutting Self-cutting –Patient: So what if I cut? Lots of kids cut. Q. What do you say? –A. Clinician: I agree, you should keep cutting. –B. Clinician: What makes you want to cut? –Patient: It takes away the pain, and I feel less anxious after. –Clinician: I agree, we need to find a way to help you to take away the pain, and help you feel less anxious.

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What if my patient gives me an unhealthy goal? Suicidality Suicidal ideation –Patient: I’ve had thoughts of killing myself, I can’t take it anymore. –Clinician: What makes you want to kill yourself? –Patient: I’m depressed all the time, and I just want to stop feeling like this. And my parents just fight all the time. –Clinician: I agree, we need to find a way to help your mood. And we need to find a way to help stop your parents from fighting all the time.

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Suicidal ideation: What’s the healthy goal Suicidal ideation –Patient: I’ve had thoughts of killing myself, I can’t take it anymore. Q. What do you say? –A. I agree, you should kill yourself. –B. Clinician: What makes you want to kill yourself?

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What if my patient gives me an unhealthy goal? Suicidality Suicidal ideation –Patient: I’ve had thoughts of killing myself, I can’t take it anymore. Q. What do you say? –A. I agree, you should kill yourself. –B. Clinician: What makes you want to kill yourself? –Patient: I’m depressed all the time, and I just want to stop feeling like this. And my parents just fight all the time. –Clinician: I agree, we need to find a way to help your mood. And we need to find a way to help stop your parents from fighting all the time.

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Interventions in the Primary Care Office

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Is there really much that I can do in a 15-minute appointment?

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Brief interventions can make a difference Evidence suggests that brief interventions result in greater reductions in alcohol consumption and heavy drinking days compared with usual care (Jones, 2012) Primary goal is to prevent or reduce alcohol use

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Brief Interventions Express concern –Be empathic, and explain your concerns about alcohol use Provide feedback linking drinking to health –Describe how drinking might affect health and safety E.g. Mixing alcohol and drugs is dangerous E.g. Unwanted sex (or sexual abuse) is more likely to happen after drinking alcohol or using drugs, or being around those who are drinking or using drugs

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Brief Interventions (Tentatively) offer advice, as opposed to giving it –Do not drink and drive –Do not ride in a car driven by someone who has been drinking or using drugs –Help the youth with what to say and do if Offered alcohol or drugs Offered a ride driven by someone who has been drinking/using drugs

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Brief Interventions Elicit response, assess readiness to change, and support goal setting, if ready –Support patient in selecting a goal –Goals depend on their stage of change Pre-contemplative and Contemplative –Monitoring, such as filling out drinking diary –Identifying triggers Action –Decreasing/stopping drinking

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Brief Interventions Offer to refer to an addictions or mental health professional

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Core principles in working with youth with addictions (or any negative behaviours)

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How Family Dinners Really Help Eating dinner is correlated with good attachment, but it is not eating dinner per se Ask yourself: –Does the child turn to parents for needs? (i.e. as opposed to primarily relying on peers/drugs)? –Does the child turn to parents for emotional needs? (e.g. expressing feelings, allowing parents to soothe difficult feelings, as opposed to relying on peers/drugs)

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Neufeld’s Six Stages of Attachment: A way of seeing how close a relationship is (i.e. how well attached)

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Britney’s mother “But I am close to my daughter. We eat dinner together every night. I still don’t understand why she doesn’t listen.”

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Britney’s Story Yes, I do spend a lot of time with my mom, but I can’t talk to her… She worries too much… She nags me and lectures me… Nothing is ever good enough for her.

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How connected are you to your child? Do you and your child  1. Spend 1:1 time together?  2. Have things in common?  3. Prioritize each other’s relationship over other competing distractions and relationships?  4. Enjoy doing things and being helpful for each other?  5. Express affection to each other?  6. Does your child openly come to you to share feelings, and do you validate/support your child unconditionally? Neufeld’s Six Stages of Attachment, 2005

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Deep relationships are better than shallow Deep relationship E.g. “I spend time with my dad, we have lots in common, he puts me first, he always tells me he love me, and I can tell him anything.” Shallow relationship E.g. “I spend time with my dad, but can’t talk about anything with him”

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The Most Powerful Strategy to Connect: Empathy and Validation

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Empathy and Validation Every one has the core need to feel loved and accepted no matter what No matter how they are feeling No matter how successful/unsuccessful No matter how good/bad No matter how smart/dumb, etc….. Parents can and need to be able to meet this need better than a child/youth’s peers

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Even your spouses can’t meet this as well as only parents can…

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For the men in the room… Your girlfriend/wife/female friend tells you a problem she is having with a co- worker at work… Q. Most of the time, what does she want? 1) Your brilliant advice 2) Your listening, validation and support

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Listen for feelings, accept and validate (Connection before Direction) SOOTHE “We’ll get through this…” “How can I support you?” “Do you want me to listen?” “Or do you want some advice?” EMPATHIZE “I can see that you’re feeling really sad about this…” (giving supportive hug) VALIDATE/ACCEPT “That’s okay if you’re feeling sad…”

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Avoid advice, minimizing, invalidating “You’re feeling sad about that? Come on, there’s a lot worse things than that… Don’t worry about it… Don’t cry… There’s a lot of fish in the sea…” “You need to just get over this…”

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Crying is good because parents can then provide comfort When your child is upset, explore your child’s feelings so that your child can ‘grieve’ about whatever the stress is Crying with a parent is therapeutic: 1) It helps your child’s brain process the sadness 2) It helps your child see that s/he can turn to you for support

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Empathy and validation: Connection before direction Its Tuesday after a long weekend, and you need a favor from a co-worker; your co- worker could say no Q. What do you say? A. “I need you to do this for me right now!” B. “Good morning!” “How’s it going?” “How was your weekend?” “How are the kids doing?”

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Other ways to connecting based on Neufeld’s Stages of Attachment

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Spend 1:1 time with your child ▪Invite your child to spend 1:1 time with you ▪Have “dates” ▪1:1 time encourages deeper communication and connection ▪Example ▪Car rides together (good) ▪Going for a hot chocolate together (better!) ▪Warning sign is a youth that doesn’t want 1:1 with a parent

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Connect through things in common We feel closer someone when we are similar or have things in common Find things in common with your child, such as – Interests and activities… – Shared memories – Warning sign is a youth that wants nothing in common with parents

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Prioritize your child When you are with your child, show your child that you value your attachment to your child over your cell phone, , texting and other distractions… Warning sign is a youth that does not prioritize parent, or vice versa Cats in the Cradle, Cat Stevens

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Be helpful and useful to your child Counter the tendency in Western society to encourage kids to be overly independent and not need us anymore You WANT your child to be dependent on YOU You do not want your child to be overly dependent on others, or turning elsewhere…

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Be helpful and useful to your child Surprise your child every once in awhile by doing things that your child should be able to do on their own –Driving them –Helping when they are short on time –Picking up stuff they need, etc. Warning sign is a youth that refuses help or being dependent on parents

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Express love and affection Harlow’s monkey experiments showed that monkeys required physical affection for development Children and youth need affection, both physical and emotional Warning sign is a youth that refuses affection from parents

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Attachment Strategy: Bridge Separations by Talking about the Reunion

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Q. You’re just had a great date with someone, and you want to see the other person again… What do you say? 1) “I had a wonderful time. Bye! ”, or 2) “I had a wonderful time. Want to get together on the weekend?”

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Whenever there is a separation, talk about the next reunion If you as an adult would feel insecure about a lack of bridging, then think how insecure a child would feel...! Children naturally feel more insecure because they are still forming their primary attachments with caregivers… ChildAdult Neufeld, 2005

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Whenever there is a physical separation, talk about the next reunion Before your child leaves for school –Parent: “See you after school” “Can’t wait until we go for our walk later after school” –Text your child during the school day –Give your child transition objects, e.g. notes in your child’s lunch box; special jewelry or possessions Before parent leaves for an errand –Parent: “See you in an hour” Before bedtime: –“See you in the morning” “What do you want for breakfast?” Neufeld, 2005

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Whenever there is an emotional separation, talk about the next reunion Parent: –“I really can’t let you talk to me that way. It is unacceptable. You need to go to your room and cool down.” (or, if that isn’t going to happen, “I need to go to my room and cool down.” Bridge the separation –“Let’s get back together in 20 minutes if we’re both calmer then” –“I love you; we’ll talk about this later and work it out.” Neufeld, 2005

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When there is a reunion, ensure there is a greeting When the child wakes up in the morning –“Good morning!” When child comes home after school –“Hello!” “Good to see you!” –“I was thinking about you doing your presentation when I was at work today” When parent sees child after a longer than usual absence –“I missed you so much” “I was thinking about you” “It wasn’t the same with you gone” Neufeld, 2005

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Management and Intervention

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Motivational Interviewing and Stages of Change Recognizing Readiness to Change and Matching Tasks to Goals

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What is motivational interviewing? Powerful way of interviewing patients used originally for substance use and addictions Can actually be used for any negative behaviours (where patients don’t think they have a problem with their behaviour) E.g. –Self-Cutting –Eating disorders –Unhealthy behaviours in chronic conditions (e.g. diabetes, asthma, cardiovascular, etc)

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How does change occur? Most change does not happen as a result of an expert physician giving brilliant advice Most people who change their addictive behaviors do so on their own, with no formal treatment Those who change go through the same sequence of change stages, whether or not they received help “Resistance” / “non-compliance” arises from strategies that are inappropriate to the client’s stage of change

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“Connection before Correction” Perhaps the most important is keeping the relationship between the patient and the physician If you can’t change ‘em, then book a follow-up! Q. What keeps patients coming back? –A. Feeling judged and criticized –B. Feeling accepted and validated

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“Connection before Correction” Perhaps the most important is keeping the relationship between the patient and the physician If you can’t change ‘em, then book a follow-up! Q. What keeps patients coming back? –A. Feeling judged and criticized –B. Feeling accepted and validated

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Precontemplation Patient is not considering change, and does not recognize the need for change The youth does not agree with clinician (or parents’) goals for change Example –Patient: “Yes, I smoke pot. I don’t have a problem. I feel better and focus better on it.”

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Precontemplation Q. Does this teen look ready to stop smoking pot? Q. What is this teen’s likely response when the clinician says… “You should stop…”

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Talking with the Precontemplative Teen Goal: –Get the patient to think about change –Be non-judgmental and accepting (i.e. forming a relationship/attachment with the patient), so the patient comes back Clinician –“What do like about smoking?” “What don’t you like?” –“What warning signs would tell you the pot is a problem?” –“Have you tried to change in the past?” “Why?” –“So it sounds like pot is one of the few ways you have to cope with all the stresses right now” –“The door is always open if you want to talk about this later”

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Principles of working with Precontemplation As physicians, we are used to people following our brilliant advice In addictions work, we have to hold back, and resist the urge to be the all-knowing physician

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Contemplation Patient is considering change, but the person is not ready to commit to change There is not yet agreement on goals (and hence not tasks) Example –Patient: “Yeah, I’d probably save a lot of money if I didn’t waste it on weed. But right now, things are too stressful, and I’m not ready to cut back.”

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Talking with the Contemplative Teen Help the patient examine benefits and barriers to change Examples: –“In what way do you want things to change?” –“Why do you want to change at this time?” –“What is your goal?” –”What would be some of the good things about making a change?” “What would you miss if you made this change?” –“What would keep you from changing at this time?” –“What might help you with that aspect?”

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Talking with the Contemplative Teen (cont’d) “It sounds like things can’t stay the way that they are now, what are you going to do?” “How would you like for things to turn out for you, ideally?” “What are your options?” “What things have helped in the past to change?” “what change could you make before your next visit?”

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Action Person is actively wanting to change, they are ready, willing, and able There is agreement on the goal of change, and (possibly) agreement on tasks Example –Patient: “I really need to stop using. Can you help me with this?”

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Approach to Action Stage “What supports do you have in place for this change?” “Have you set a quit date?” “How do you see things in 1 month, 3 months?” “Where will you be going for counselling?” “How about I see you in two weeks so that you can tell me how the program is going?”

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Approach to Action Stage There is agreement on the goal of change, but remember to collaborate on coming up with the tasks Examples –Clinician: “Its great that you want to stop using marijuana. How would you like to go about doing that?” –Clinician: “Its great that you want to find some other ways to cope. What other ways have you thought about?” –Clinician: “How can I be helpful and support you in this?”

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Maintenance Person is adjusting to change, and acquiring and practising new skills and behaviors that support the change Example –Patient: “I’m off weed right now. Its not easy, but I’m trying my best. I don’t want to disappoint my parents or my girlfriend.”

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Review of Objectives This presentation will review: 1.How to screen for youth with alcohol/drug problems 2.How to help youth in the office using motivational interviewing and interpersonal strategies, with a focus on… 3.How to empathy, validation and unconditional acceptance is perhaps the most powerful way to reconnect youth to parents and vice-versa